At the ER, the stay can reach 8 hours

Loss of beds at major Bay State hospitals is blamed

By Liz Kowalczyk, Globe Staff | March 25, 2007

Receiving care in a Massachusetts hospital emergency room takes two-and-a-half to three hours on average. But patients typically spend four to five hours in the ERs of several large Boston teaching hospitals before being discharged. And for more than 80,000 people during one year, their visit took upward of eight hours, according to a report commissioned by the Globe.

Several emergency medicine doctors said ERs have been more crowded since the early 1990s, partly because economic pressures forced a 25 percent reduction of hospitals beds in Massachusetts, creating more backups in the ERs. Crowded conditions mean patients can spend longer in the waiting room, longer in ER beds waiting to be seen by a doctor, and longer waiting for X-rays and other tests, and for test results. In recent years, hospitals have been trying to get patients out faster by ordering tests sooner and hiring more staff.

But the doctors said in interviews that progress has been uneven and more hospitals are spending millions of dollars to expand their emergency rooms as a possible solution.

Between October 2004 and September 2005, the most recent year of comprehensive data available, time spent in the ER, from registration to discharge, ranged from 1.4 hours at tiny Baystate Mary Lane Hospital in Ware to 5 1/2 hours at busy Massachusetts General Hospital in Boston, according to the report provided by the Massachusetts Health Data Consortium. Island hospitals on Nantucket and Martha's Vineyard also had some of the shortest ER stays.

In Boston, Brigham and Women's Hospital and Beth Israel Deaconess Medical Center took an average of four to five hours to treat patients, while visits at Boston Medical Center typically lasted 2.8 hours, close to the statewide average.

Emergency room doctors said that several factors contribute to the length of ER stays. Many large teaching hospitals treat sicker patients, physicians pointed out, which may require doctors to order more tests and spend more time making a diagnosis. Since ER staff tend to the sickest patients first, people who arrive at a busy teaching hospital ER with the flu, a backache, or nausea can spend hours though they have a relatively minor problem.

"We've just taken our ERs and saturated them beyond the point of effectively functioning," said Dr. Ron Walls, chairman of Brigham's emergency department. "We've super-saturated them."

Hospitals that treat large numbers of psychiatric patients in their emergency rooms also tend to have longer turnaround times. Because of a shortage of treatment facilities, average stays for these patients are nearly six hours statewide, but can reach days. They spend longer in ERs than patients with other conditions and can contribute to delays for other patients.

Dr. Alasdair Conn , chief of emergency services at Mass. General, said that about 18 months ago he and his staff treated a mentally ill child in the emergency room for seven days before they could locate a bed at a pediatric psychiatric hospital in a nearby state. Mass. General treats thousands of mentally ill patients in its ER.

The data provided to the Globe involve only patients who are sent home or to another facility, not patients who are admitted to the ERs' own hospital. Those patients are considered in patients and are not part of the state's emergency room database. But ER directors at several hospitals said these patients who are admitted to the hospital are spending longer in the emergency room, too, and probably would push up their hospital's average ER stay. At hospitals that are full and have few empty beds, patients can wait many hours on beds in the corridors in the ER.

Economic pressures also can play a role in keeping those patients waiting, as hospitals keep beds as full as possible with elective surgery patients, leaving less wiggle room for emergencies. A hospital's popularity is a major factor, too.

"We have sick people in the waiting rooms and sick people in the hallways," Conn said. "I usually go into the waiting room and tell people it's like you're in a hotel lobby waiting to book a room and all the rooms are occupied. People seem to get that."

Since 2003, Massachusetts hospitals are required by the state to report detailed information about emergency room visits, including what time patients register and what time they are discharged.

The Massachusetts Health Data Consortium, a nonprofit founded by healthcare providers, obtains the data from the state and produces reports, mostly for hospitals. The Globe purchased a report on emergency room stays for 70 hospitals for fiscal 2003 and fiscal 2005.

In 2003, average emergency room stays were about the same as they were in 2005.

Overcrowding is a major issue in emergency rooms across the United States, but the problem appears to be worse in Massachusetts, where the decline in hospital beds over the past two decades has been more dramatic.

Many people have a story about a maddeningly long wait in the emergency room for a child's fever, back pain, a broken leg, or an unexplained stomachache. On Yelp.com, a website on which users write reviews about a range of services, people regularly write their opinions about hospital ERs and give tips on getting faster treatment.

"If you're in need of an ER, go to B.U. Medical Center (formerly Boston City Hospital) instead," one young woman wrote last month. "They are known for processing ER patients within an hour or less. (They're also known for being the go-to hospital for gunshot wounds, but don't let that scare you away.)"

Even though only about 13 percent of the patients at Boston Medical Center were discharged in less than an hour in 2005, according to the report, the waits are longer at most other Boston teaching hospitals.

Sometimes patients get hung up at particular points in their ER visit, for reasons unclear to them, increasing their frustration with the wait.

When her husband, Greg, cut a finger using a table saw six weeks ago, Kathie Sportum drove him to Caritas Holy Family Hospital and Medical Center in Methuen, the closest hospital to their home in Plaistow, N.H. They arrived about 6:30 on a weeknight.

"It was packed, so I knew we were going to be there for awhile," she said.

However, she was surprised it took four hours. (The average stay in the Holy Family ER was 2.7 hours in fiscal 2005.) Waiting for a physician took the longest; the doctor spent less then 10 minutes examining her husband's cut and ordered an X-ray, she said. A physician's assistant returned to put in the 10 stitches.

Some hospitals are using their shorter wait times to try to draw patients.

In ads last fall for its new pediatric ER, Tufts-New England Medical Center said doctors see most patients within a half-hour. MetroWest Medical Center has erected a billboard on the Massachusetts Turnpike promising 30-minute "door-to-doc" service at its Leonard Morse Hospital in Natick, and is promoting the program to ambulance companies.

The hospital's overall ER stay was 3.3 hours in fiscal 2005, the state data show, and, hospital executives said, dropped to 2.8 hours last year -- roughly average in Massachusetts.

Still, Tom Hijeck, the chief nursing officer, said the hospital is keeping its promise to have a doctor see a patient within 30 minutes, even if the entire visit takes longer. "When patients come into the ER, what is most meaningful to them is when a provider assesses them," he said.

Some physicians are concerned not only about patient convenience, but about safety.

The medical malpractice company for the Harvard teaching hospitals -- including Mass. General, Brigham's, and Beth Israel Deaconess -- has identified patients waiting in the ER for hours for a hospital bed as an area of concern based on a small number of claims from patients.

Those claims usually involve possible mistakes as one ER shift hands off patients' care to the next group of doctors and nurses. The company recently advised the hospitals to clearly define when doctors and nurses who work on the inpatient floors take over responsibility for long-term ER patients from the emergency department staff.

ER directors said they are trying new measures to reduce patient stays : Mass. General has opened a 14-bed unit on the 12th floor where ER doctors and nurses can monitor patients, such as those with mild chest pain or infections, for less than 24 hours to determine whether they can be sent home. The new unit has freed up space in the ER, and Conn said stays for patients being discharged have fallen to about five hours on average. Both Mass. General and Brigham and Women's are planning expansions.

At Mary Lane Hospital, people have driven from Connecticut for care because of the hospital's well-known fast turnaround time, said Dr. Richard Gerstein, medical director. Once word gets out about a hospital's fast patient turnaround time, that news alone sometimes attracts more patients -- and can lead to delays. Gerstein said he is determined not to let this happen, but it will be difficult.

The number of visits to the ER has grown nearly 9 percent over the same time last year, because the population in nearby Belchertown is exploding and "patients are coming to us from more distant locations because word is out," Gerstein said. He has hired more staff.

"Our community has been spoiled by the relatively short rates, and we don't want to lose those people," he said.

Matt Carroll of the Globe staff contributed to this report. Liz Kowalczyk can be reached at kowalczyk@globe.com.